HomeMy Public PortalAbout5727 ALESSANDRO AVE_Miscellaneous__ WORKERS'COMPENSATION DECLARATION
CE 875 (11-84) MISCELLANEOUS APPLICATION
CE 875
I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec. 3800,Lab.C.).
Policy No. Company FOR APPLICANT TO FILL IN BUILDING
ADDRESS
Certified copy is hereby furnished. AU I LD I N o,gr d, !
LOCALITY
ElCertified copy is filed with the county building inspection LOCALITY s NEAREST
department. / � ! CROSS ST.
Date Applicant NEAREST DISTRICT NO. GROUP TYPE PROCESSED BY
CROSS ST. ^ CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPTION LOT NO. r"`� BLOCK MAP HIGHWAY
NOF rvo. (CIRCLE) STATE MAJOR SECOND LOCAL
. O
(This section need not be completed if the work involved TRACT NOW ONBLD GS.LOT .4,,,. USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) S E 0
SIZE OF LOT -
�"t �'' EXISTING BZ•D G. °' V
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any mannerOWNER " h
� `� �4I
so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP �-
ADDRESS rA A,,: e
Date Applicant / d
NOTICE TO APPLICANT: If, after making this Certificate of CITY`T ,Ej j) E' No� . , OCCUPANT LOAD o
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- APPLICATION FOR EXIT HARDWARE: ❑ w
with comply with such provisions oI this permit shall be TRAILER USEGEOLOGY INSPECTION ~
❑ ❑ No Spec. Knowl.
deemed revoked.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTIONEJ_- Panic Devices
I hereby affirm that I am licensed under provisions of Chapter
9 (commencing with Section 7000) of Division 3 of the Busi- SAFETY PERMIT (LIST ITEMS BELON NO. OF EXITS
tress and Professions Code,and my license is in full force and �r / /yq ,/ J
effect. ��{ / A 45' r;' PARKING
SPACES REgD O PROVIDED D
'License Number Lie. Class 7
LIMITED TIME USE
Contractor Date � yr y' e DATE DATE
❑ I am exempt from the licensing requirements as I am a > ~
licensed architect or a registered professional engineer SIZE OF No. of FROM: ro: INSPECTOR S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE
iness and Professions Code). y FINAL APPROVAL
PRESENT USE OF BUILDING LI A .t� f, ffL�j{,/'
Lic.or Reg.No. Date
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS
1 ON LOT AND USE .f+
III I hereby affirm that I am exempt from the Contractor's
License Law for the following reason (Section 7031.5, Busi-
ness
usi ness and Professions Code): NO. PARKING J
I, as owner of the property, will do the work and the SPACES PROVIDED G:..
structure is not intended or offered for sale (Section
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY PROPOSED USE of BUILDING
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is
issued(Sec. 3097,Civ.C.).
Lender's Name
ePROPOSED MAX. OCC.
Lender's Address
PERMIT FEE
ILcertify that I have read this application and state that the
above information is correct.I agree to comply with all County ISSUANCE FE E
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter TOTAL FEE q!
upon 4e abov&mentioned property for inspection purposes.
1 s 1! SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date
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